with cross-finger pedicle grafts

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1 Salvage of digits with cross-finger pedicle grafts Robert I. Horner, MD and Floyd B. Bralliar, MD Mechanization in home and industry has brought to our emergency rooms an increasing number of patients with a variety of hand injuries. Among these is soft tissue loss in a digit. When confronted with this, a surgeon should be prepared to use whatever procedure is necessary to provide the best coverage. Cross-finger pedicle flaps have been found useful in many cases and have been discussed by various authors Floyd Brallior, MD, is in private practice in hand surgery in Denver. He was educated at Pacific Union College and Loma Linda University, California. Dr. Brallier served his internship at the USPHS Hospital, Staten lslond, NY, and surgical residency in Son Francisco, USPHS Hospital. Robert L. Horner, MD, FACS, graduated from the School of Medicine of Lomo Linda University and took a rotating internship at the Lor Angeles County General Hospital. He completed studies in orthopedic surgery at the University of California 10s Angeles Medical Center, and served more than six years as an orthopedist in Puerto Rico for the Bureau of Crippled Children. In addition to the American Col- lege of Surgeons, Dr. Horner is a fellow of the American Academy of Orthopedic Surgeons. He is in private practice in hand surgery in Denver. To assess the role of cross-finger pedicle flaps we have reviewed the types and their results in 65 patients who had this operation on 71 separate digits during a recent five-year period. The majority of our cross-finger pedicle flaps were used for primary coverage of injured digits where there had been exposure of bone or tendon, but 19 operations of this type were done for coverage after contracting scars had been excised. Defects of the digit tips and volar surfaces of digits were inost frequent, but occasionally the dorsal surface of the thumb, or other digits, was covered by a flap from an adjacent finger. Dorsal surfaces were used as donor areas in all cases. The patients ages varied from 2 to 62 years. The length of foliow-up was over 1 year in all cases, averaging 3 years and lasting as long as 5.5 years. With involvement of mutliple digits, a variety of closure methods were utilized, including double cross-finger pedicle flaps (Fig 1 ) in four; triple in one; 66 AORN Journal

2 Fig 1 Fig 2 A deep grinder injury to the dorsum of the thumb caused loss of the dorsal one-third of the distal phalanx and of the nail matrix. a combination of a cross-finger pedicle graft with a pedicle graft with a pedicle flap from the torso in three; and with a palmar pedicle graft in one. A summary of the cross finger pedicle source is as follows: areas covered by flaps with their thumb: 13-3 from long finger, 10 from index finger indexfinger: 17-3 from thumb, 14 from long finger long finger: 21-6 from index finger, 11 from ring finger, 4 from thumb ringfinger: 11-7 from long finger, 4 from little finger little finger: 9-all from ring finger All surgery was done in the operating room with an anesthesiologist in attendance and with a pneumatic tourniquet in place on the upper arm. After sterile preparation of the skin, the involved area was prepared by thorough debridement or scar excision. The final decision concerning the coverage to be used in a particular case was not made until this stage. A dorsal flap from the index finger was elevoted and sutured over the defect. The donor area and the exposed portion of the pedicle graft was covered with a split-thickness free skin graft from the buttock. Repair of involved deep structures was occasionally performed at this time. This included open reduction and internal fixation of fractures of the phalanges, suture of nail beds and repair of digital nerves. No tendon repairs were performed concurrently. Several cases, originally considered best treated by a cross-finger pedicle flap, were found to be unsuitable for this procedure. Alternate means of closure were used, such as phalangeal shortening and direct closure, free skin grafts or a pedicle flap from the torso or palm. The injured digit was tested in various positions in an attempt to determine the location of the best donor site. In the typical case of a distal volar defect, it was found that a flap based on the midlateral line of the adjacent finger could be elevated and placed over the involved area. To avoid contracting scars, longitudinal incisions were placed as near as possible to the midlateral line of the donor digit, even if this made the flap larger than necessary for coverage. November

3 Proximally-based flaps were used to cover dorsal defects of an adjacent digit. Such a pedicle flap from either the index or long finger could be used to cover the thumb tip (Fig 1-5). Distally-based flaps were avoided because of lack of adequate venous return. One attempt in a case subsequent to this series demonstrated the problems which may be encountered when all normal venous channels have been disrupted. Before the flaps were elevated, they were carefully outlined in marking ink, but it was not found necessary to cut out patterns. Careful measurements were occasionally made to be sure that there would be adequate length for complete coverage. To avoid tension it was found necessary to be generous in the sizeboth width and length-of the flap. If all tension on the suture line could be avoided, immobilization did not need to be exact. Tissues were handled largely by skin hooks, avoiding the use of forceps on the skin which would be transferred. Fig 3 Saline-soaked cotton is placed over the grafts be- fore application of a bulky dressing. The deep portion of the dressing is left in place until 18 to 21 days after the surgery when the dressings and sutures are removed and the pedicle is separated and sutured into position. Coverage of donor areas was by free split-thickness grafts taken with an electric dermatome set at about,015 inch. The ulnar aspect of the upper forearm was commonly used in men as a source of the split skin graft, but usually the buttock was utilized in women and children. The split-thickness skin graft was carefully sutured in place with 5-0 nylon to cover the donor area and the under side of the unattached portion of the pedicle flap. This required that it be fixed to the adjacent side of the original defect, across the open surface of the pedicle flap and then used to cover the defect of the donor finger. Immobilization was provided by compression dressings, frequently using plaster splints but often depending on saline-soaked cotton balls (Fig 3) held in place by circular bandages over fluffed-up cotton gauze. No metallic fixation was used between the digits. The pneumatic tourniquet was usually not released until the dressing was complete. Overnight hospitalization was insisted upon to assure complete elevation. The patients were allowed to ambulate only when they agreed to keep their involved hand overhead for five to ten days. Dressings were not ordinarily changed until after 18 to 21 days when anesthesia was again provided in an operating room. The pedicle was separated, the margins trimmed and carefully approximated to insure primary healing. Frequently it was possible to lay much of the proximal portion of the pedicle flap back on the donor area, excising a portion of the split graft and thereby minimizing the scar on the donor digit. Minimal dressings were then applied and active finger motions were encouraged the second day after separation. 68 AORN Journal

4 Each of the patients was carefully evaluated, when they had made maximum improvement? for impairment of motion and sensation. All 65 of the patients having this type of surgery had some sensory deficit in the injured digits. In 44 patients there was no measurable limitation of interphalangeal motion. Varying degrees of loss of joint motion in the involved digits were noted in 21 patients; and 16 of these had had definite associated injuries in the digits other than simpie soft tissue loss. Fig 4 Almost all of the grafted tissues healed completely but two patients had necrosis of a portion of the pedicle graft, the necrosis measuring more than 10% of the area of the defect. Further grafting was not needed but there was a delay in healing, and decreased flexibility of skin due to adherence to deep structures. Three patients had subsequent amputations of the involved digits because of severe stiffness and irreparable sensory loss due to crush injuries. The patients were evaluated according to the following criteria: Good - less than 10 degrees total limitation of interphalangeal motion in avulsions and lacerations, less than 30 degrees total limitation of motion in crush injuries. Fair - more limitation of motion than allowed in good but less than a total of 60 degrees. Four months after the injury, he has good function with no hypersensitivity. There was 15 degree limitotion of interpholongeol flexion of the thumb but no other limitation of thumb on index finger motion. Because of the location of the original defect, no attempt was made to preserve sensation in this pediclo graft. Poor - some function of the digit but less than in fair. Failure-no function of the digit or subsequent amputation required. Fig 5 Seven patients had a loss of more than a total of 30 degrees of motion in the interphalangeal joints of the injured digits. Four patients had a similar loss of motion in the donor finger-in two of them four digits had been significantly injured at the time of the initial trauma. None of the patients under 16 years of age had limited motion. All but one of the patients over 50 years of age had some stiffness. November

5 Results of the study showed 51 patients rated good, 7 were fair, 3 were classed poor, and 4 failed. In an injury where bone or tendon is exposed we feel that a cross-finger pedicle graft is indicated if a nearnormal length of the digit can thereby be preserved with the distal joint, and especially if the nail matrix is intact. When only the skin is lost and there is sufficient padding, a free skin graft either split or full thickness may be adequate. However, the cross-finger pedicle grafts did not show the hypersensitivity frequently found in free grafts on the finger pads. If only one digit is involved in the injury it is usually best to shorten the bone until good coverage can be obtained by tissues with normal sensation. The need for reconstruction increases, however, as the thumb or multiple digits are involved. Scar contractures which involve deep structures in proximal areas of a digit occasionally require a pedicle flap. A cross-finger pedicle flap may be useful in these cases and the resulting sensory deficit is not a significant factor since the finger pad is not involved. Since the sensory deficit following reconstruction of the thumb pad by a pedicle flap causes a significant disability, an attempt has been made to overcome this problem with a sensory crossfinger pedicle graft5 from the dorsum of the proximal portion of the index finger, similar to that described by Fessati.1 A proximally-based flap is used to cover the thumb defect. The branch of the radial nerve to the radial side of the dorsum of the index finger is preserved and at the time of separation of the pedicle flap is placed in a new bed along the ulnar side of the thumb. This requires a modified U-shaped incision along the dorsum of the thumb web. An attempt was made in five patients of this series to provide thumb sensation along with adequate coverage by this type of pedicle graft from the index finger. In most individuals, the radial nerve branches supply satisfactory sensation to the skin over only the proximal two-thirds of the dorsum of the proximal phalanx. Where more distal skin was used in the pedicle graft there was a definite diminishing in the quality of the sensation. By this method, using two point discrimination varying between 4 and 8 mm, three of the five patients were provided with satisfactory sensation to the thumb. In conclusion, cross-finger pedicle grafts have a definite place in reconstructive hand surgery. When adequate tissue is available they are preferable to pedicle flaps from the torso and give more satisfactory coverage than free grafts when bone or tendon is exposed. Permanent loss of good sensation in the grafted area is to be anticipated but the preservation of length with corresponding ability to grasp, more than compensates for the loss of fine tactile sense in most cases. Some loss of motion in the donor and recipient digits is to be anticipated if there has been a crush injury, and especially if the patient is past 50 years of age. Technics are available for providing sensations to the thumb along with a pedicle graft. Evaluations have been made of 65 patients who have had 71 consecutive cross-finger pedicle flaps. The results have indicated that this operation has 70 AORN Journal

6 real usefulness where a full thickness of skin along with sufficient subcutaneous tissues is needed. Occasionally sensation can be supplied to the grafted areas by nerve trans- position. CI REFERENCES 1. Fossati, Guillermo H.: Los Colgaios lnervados en Cirugia de la Mano Sol. de la SOC. de Ciru- gia del Uruguay, , Gurdin, Michael, and Pangman, W. J.: "The Repair of Surface Defects of Fingers by Trans- digital Flops," Plart. and Reconstruct. Surg., 5: , Horn, J. S.: "The Use of Full Thickness Hand Skin Flaps in the Reconstruction of Injured Fingers," Plast. and Reconstruct. Surg., 7: , Hoskins, H. Dean: "The Versatile Cross-Finger Pedicle Flap," J. Bone ond Joint Surg., 42-A: , March Brallior, Floyd, and Hornet', Robert: "Sensory crosr-fhger pedicle graft," J. Bone and Joint Surg., 51 -A: , October, Don't move without us. To insure uninterrupted service on your AORN JOURNAL subscription, please notify us at least six weeks before changing your address. 1. Attach your address label from a recent issue in the space provided opposite. (If label not available, be sure to give us your old address including Zip Code). 2. Print your name and new address below (be sure to include your Zip Code). 3. Mail entire notice to: Subscription Service Dept. AORN JOURNAL 8085 E Prentice Ave Englewood, Colo Name Please Print New Address ~- Zip City State Code November

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